Many states already leverage Dual Eligible Special Needs Plans (D-SNPs ) to better manage care for individuals enrolled in both Medicare and state Medicaid programs. Recent changes to federal regulation, stemming the Bipartisan Budget Act of 2018, are expected to make D-SNPs more attractive for states seeking to better integrate care for this population.
The National Academy for State Health Policy (NASHP), with support from The SCAN Foundation, convened state policymakers at its recent annual conference to explore these new opportunities, highlight Medicare/Medicaid integration efforts in leading states, and explore what internal state capacity is needed to successfully address the needs of dual-eligible beneficiaries across programs.
The session, Maximizing Medicare: New Opportunities to Support State Policy Goals, featured examples of successful D-SNP models in Minnesota and Arizona, and highlighted lessons learned from states, detailing what internal expertise is needed to support these programs.
Individuals covered by both Medicare and Medicaid present unique challenges for state policymakers. This population often has higher health care costs and poorer outcomes, including higher rates of chronic conditions and behavioral health diagnoses. For states, creating well-integrated and coordinated systems of care for this high-needs population can be hampered by the complex interplay of these two programs.
The Bipartisan Budget Act of 2018 permanently authorized D-SNPs, and final regulations require D-SNPs to coordinate Medicaid benefits for duals and assist them in navigating appeals. The new rule also requires D-SNPs – in some circumstances – to provide an integrated appeals process and discharge planning for some high-need members. All D-SNPs must meet certain minimum integration criteria by 2021.
Both Minnesota and Arizona have experienced improved integration of care for duals through use of D-SNPs. Both states leveraged the contracting requirements of the Medicare Improvements for Patients and Providers Act to align administration and improve consumer experience. Wisconsin has structured its program to provide a more integrated experience at every step, including one set of enrollment materials, aligned enrollment dates, and care coordination for primary, acute, and long-term care services. Arizona’s D-SNP plans must be contracted “companion” plans with the Arizona Health Care Cost Containment System (AHCCCS), the state’s Medicaid agency. This and other contract features help encourage member enrollment in the same health plan for both Medicare and Medicaid services.
What internal capacity is needed to make these programs work? Presenters offered the following key takeaways:
- Leadership is critical: Strong leadership is an important factor in providing more integrated care for duals. Leadership that understands the complexity of the population, and the need to mobilize specific resources and policies to address their unique issues and make long-term investment in these programs has been an ingredient for success in leading states.
- Build and nurture strong managed care organization (MCO) partnerships: Collaborative relationships with Medicaid MCOs are also central to integrating care across programs. To avoid misalignment, presenters suggested working with MCOs to review detailed descriptions of the services to be coordinated by D-SNPs, including behavioral health and long-term services and supports, and discussing enrollment, marketing, and appeals policies with them to identify and resolve issues.
- Engage stakeholders: Similarly, states found it helpful to regularly engage a range of stakeholders – providers, members, and advocates – to identify specific needs and areas of disconnect, and to allay consumer and provider concerns who may be impacted by policy changes.
- Focus on staff capacity and ongoing training: States emphasized the need to have subject matter expertise within a state Medicaid agency. One presenter noted, “integration is a process and not an event,” long-term capacity is necessary to be able to analyze and respond to the changing state and federal regulatory landscape on an ongoing basis. Having designated staff and facilitating clear lines of communication across offices within Medicaid with an “open door policy” can also help identify and troubleshoot issues. Important areas of expertise include accessing and using Medicare data, understanding covered services and payment, and familiarity with state policy options to better integrate care.
Presenters encouraged policymakers to make full use of available resources to help them better understand the policy issues and needs of dual eligibles. The federal Medicare-Medicaid Coordination Office (MMCO) was noted as an excellent resource. MMCO leaders recently released a State Medicaid Director Letter detailing how states can improve care for dually-eligible beneficiaries. Additionally, the Integrated Care Resource Center website also provides a host of state-specific materials and learning opportunities.
Additional information and copies of slide presentations from NASHP’s 2019 conference is available on this Conference Presentation page.